Borneo Journal of Medical Sciences (2016) volume 10, issue 1, pp: 59-74

Worm Infection among Children in Malaysia

Lim-Leroy A1*, Tock H. Chua1
1
Department of Pathobiology and Medical Diagnostics, Faculty of Medicine and Health Sciences, Universiti
Malaysia Sabah, Kota Kinabalu, Malaysia

*
Corresponding author’s Email: 1912alp@gmail.com Phone: +6088-32000 Ext 5360 or +6013-8942788

(Received: August 14, 2015; Accepted: November 3, 2015)

ABSTRACT

Parasitic worm infections, particularly by soil-transmitted helminths (STHs), are considered a public
health concern affecting millions of children in developing countries around the world. In Malaysia,
various prevalence studies have been carried out since 1970s among children from diverse population
ranging from the remote aboriginal communities in the Peninsular Malaysia to the rural interior tribes of
Sarawak. However, the number of worm infection studies in Malaysia is still limited particularly in East
Malaysia but overall, more studies should be conducted presently compared to 20 years ago. Focusing
mainly on STHs, we reviewed the prevalence and intensity of worm infection among children between
East Malaysia and West Malaysia, particularly from rural and urban settings.

Keywords: worm infection, children, Peninsular Malaysia, Sabah, Sarawak

INTRODUCTION

Worm infection, also known as helminthiases, is a serious public health concern in either
underdeveloped or developing countries. There are two major phyla of parasite worms – the nematodes
(or roundworms) which include the major importance soil-transmitted helminths (STHs) as well as filarial
worms; and platyhelminths (or flatworms) which comprise of flukes (or trematodes) including
schistosomes and tapeworms (or cestodes) 1 (Table 1). Worm infections, particularly among children, are
considered a major concern causing physical and cognitive growth retardation, hindering them from
educational advancement and economic development 2. Both pre-school and school-aged children tend
to harbour high infection rate of the three main types of STHs and schistosomes 1.

Worldwide, it has been estimated that more than two billion individuals are infected with the four
species of STHs 3. Hence, making STH the most common cause of helminthiases, followed by
schistosomes and filarial worms 1. The tropical and subtropical countries have widespread infection with
Ascaris lumbricoides, hookworms (Ancylostoma duodenale and Necator americanus) and Trichuris
Borneo Journal of Medical Sciences (2016) volume 10, issue 1, pp: 59-74

trichiura 4, 5 due to the suitable climate as well as adequate moisture and relative atmospheric humidity
which are essential for larval and ova development in the soil 6. World Health Organization estimates
that more than 880 million children are in need of treatment for STH 7. For Schistosomiasis, over 240
million people worldwide are affected and requiring treatment and out of this number, over 120 million
were school-age children between 5 and 14 years of age 8.

Another two major intestinal worms affecting millions of people globally are Enterobius
vermicularis (also known as pinworm) and Strongyloides stercoralis (also known as threadworm). E.
vermicularis which induces symptoms of itchiness of the perianal area, infects millions of people globally,
especially children 9, 10. Bethony et al. (2006), estimated 4-28% of children of the world population are
infected with E. vermicularis 5. On the other hand, S. stercoralis infect between 30 to 100 million people
11, 12
.

WHO also estimates that at least 56 million of people are infected with foodborne trematodiasis
of which four main genera of flukes – Clonorchis spp.; Opisthorchis spp.; Fasciola spp. and Paragonimus
spp are among the most common flukes affecting human worldwide 13. Estimated population at risk of
Fasciolopsis buski is unknown but this particular fluke species is commonly recorded in Malaysia 14. As
for tapeworm, the most significant public health importance is of Taeniasis which plays a crucial role in
the transmission of another form of epilepsy-causing serious disease called cysticercosis caused by the
larval stage of Taenia solium.

The objective of this review is to compare the worm infections, focuses mainly on STHs, between
East Malaysia and West Malaysia, particularly among children from rural and urban settings. Whether
there is any difference in the prevalence and intensity of worm infection based on the improvement in the
development of health care and socioeconomic conditions 20 years then and at present in Malaysia will
also be discussed.

EPIDEMIOLOGY OF WORM INFECTION IN MALAYSIA

Nematode worms especially E. vermicularis and STHs which collectively include A.

lumbricoides, T. trichiura and N. americanus are mainly found in high prevalences in Malaysia.
Compared to STH, there were only several studies on E. vermicularis infection which have a lower burden
among the adults15. Several studies of enterobiasis in Malaysia found that E. vermicularis is higher among
16-18
children of 5-7 years age group . S. stercoralis, although present, is not considered endemic in
Malaysia and usually occurs in sporadic cases 19. Studies about helminthiasis, particularly of STHs, have
already been carried out since 1969 in Malaysia 20-22. A review by Ahmed et al. (2011) listed out several
studies of STHs among children from both rural and urban settings in Peninsular Malaysia from 1979

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until 2007 23. Nevertheless, emphasis was more on underprivileged rural and Orang Asli communities 24-
29
. There were also filariasis cases reported including in rural district of Serian in Sarawak, East Malaysia
where B. malayi was reported at a low prevalence rate of 5.1% 30.

Infection with trematodes and tapeworms were reported occasionally only in adults even though
it is possible that these are present in children. For example, liver fluke infections by C. sinensis and
Opisthorchis spp were found among the Chinese in Malaysia mainly due to their habit of eating raw fish
dishes 31 32. A 39-year old Sabahan was the first reported case of F. buski infection, had neither travelled
overseas nor to any endemic areas for F. buski 33. Previously, trematode eggs were already discovered
34
and reported in Sabah in 1978 . Sinniah et al. (1978) reported about infection by tapeworms of
Hymenolepis spp in adults working at the oil-palm plantation (0.7%) in Peninsular Malaysia and not in
children 35. The first case of T. saginata or beef tapeworm was detected by PCR in the stool specimen of
a 56-year old man also hailed from Sabah (Chua, et al., unpublished data) .

More than 207 million people are infected with human Schistosoma spp, including several cases
discovered since 1975 in Malaysia 36. Reported human schistosomiasis cases diagnosed histologically
37, 38
was attained among the rural aborigine communities in Pahang and Perak in the 1970s prior to
serological surveys for schistosomiasis which showed prevalence of 4%-25% 39. The autopsy cases were
patients aged between 11-68 years old which disclosed occurrence of Shistosomiasis in Malaysian
children 36. Based on these findings, S. malayensis resembling those of S. japonicum was described in
1988 40. In 1985, schistosome eggs were found in stool samples of children aged between 2 months-18
years old in Orang Asli villages in Ulu Kelantan (1.8%) dan Selangor (1.9%) 41.

DISCUSSION

Worm infections, particularly the medically important STHs, have been well-studied in
42
Peninsular Malaysia compared to the only several reports from East Malaysia . The studies in
Peninsular Malaysia covered wider areas which include the aboriginal populations, estates and even
plantations, squatters’ dwellers and in hospitals 31, 43-45
while selectively covered only certain interior
tribal communities in East Malaysia, such as the Kayans, Kenyahs and Penan in Sarawak 46. Study in
Peninsular Malaysia covers most states such as Kelantan, Perak, Pahang, Penang, Selangor and of course,
22, 25, 47-52
the Federal Territories of Kuala Lumpur . However, data were limited only to the three main
53-56
ethnicities in Malaysia (Malay, Chinese and Indian) . This is mainly because Malay makes up the
majority of the population in Peninsular Malaysia, followed by Chinese and Indian while population in
Sabah and Sarawak are very diverse and unique with different ethnic and subethnic groups. There were
also studies conducted in island population in Peninsular Malaysia, such as Pulau Ketam, where there
were low prevalence of STH infection of only 8.4% among children aged between 5-12 years old in 1987
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57
. However, Oothuman et al. (1989) found high prevalence of E. vermicularis at 56.88% among 6-12
years old school-children from three National Chinese Primary Schools in the same island in 1988 17.

Table 1: Major human worm infection

Species of worms Disease Estimated world Recorded in

prevalence (millions) Malaysia

Nematodes

Ascaris lumbricoides Ascariasis 807 – 1221 Yes

Trichuris trichiura Trichuriasis 604 – 795 Yes

Necator Americanus & Hookworm infection 576 – 740 Yes

Ancylostoma duodenale

Strongyloides stercoralis
Strongyloidiasis
Enterobius vermicularis
Pinworm infection 30 – 100 Yes

4-28% of children Yes

Filarial nematodes

Wuchereria bancrofti & Lymphatic filariasis 120 Yes

Brugia Malayi
Onchocerciasis
Onchocerca volvulus
37 No

Trematodes

Schistosomes sp Schistosomiasis > 207 Yes for S.

malayensis
Liver Fluke
>56
Clonorchis sinensis Food-borne
trematodiasis Yes
Opithorchis spp
No
Fasciola hepatica
Yes
Lung Fluke
Food-borne
Paragonimus spp trematodiasis
No

Yes
Intestinal Fluke Food-borne
trematodiasis
Fasciolopsis buski

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Cestodes

Taenia spp Taeniasis/ 80% of the world’s 50 Yes

Cysticercosis million people affected by
epilepsy

In East Malaysia, studies and documented data on worm infections were limited. Most of the studies
were conducted in rural areas in several districts in both states where children were likely to be infected
with intestinal parasitic worms. Kan et al. (1987) carried out a study among indigenous Penan children
at Upper Baram in Sarawak whereby one-third of the respondents were found to be infected with STH 58
. Another study reported that the number of STH ova found in children from rural primary school outside
Serian town is higher than those found in older age rural secondary school children from rural secondary
school which indicates that younger children are prone to infection than older children 59. Sagin et al.
(2002) revealed that children less than 14 years old have higher parasitic intestinal infection rate at 68%
in a study conducted in seven rural villages in Bakun Valley upper Rejang River involving several tribes46.
These two studies reported T. trichiura infection as the most common worm infection in Sarawak but at
a lower infection rate compared to Peninsular Malaysia. Overall, the infection rate of STH in Sarawak
remained at a lower rate of less than 50% than in Peninsular Malaysia. Besides STH infection, S.
malayensis-like schistosomiasis was detected among the indigenous tribe in all age group at similar study
site at 6.8% seroprevalence but the highest rate were those above 60 years of age instead of children60.

Similar to Sarawak, there were scarce amount of data of worm infection among children in Sabah.
Therefore, it is difficult to estimate the overall rate of worm infection in Sabah and whether the prevalence
is higher than Peninsular Malaysia or Sarawak remains unclear. Nor Aza et al. (2003) conducted a study
in seven villages from the districts of Tambunan, Keningau and Tenom, Sabah to determine the infection
61
of these parasites among the communities living on the fringes of the Crocker Range Park . The
prevalence rate of STH was relatively low with T. trichiura, A. lumbricoides and hookworm at 10%, 8.7%
and 3.3% respectively. Low seroprevalence of 2.2% for cysticercosis was reported in a rural village in
Ranau, Sabah but there is no indication whether children were included in this study 62.

Worm infection, particularly by STH, are usually prevalently high in impoverished areas where
communities are living in poor environment with inadequate water and lack of sanitation facilities which
are common in rural areas 53, 63. It is considered a disease of poverty since parental socio-economic status
19, 23, 64
correlates with helminthiases in children . Urban population, on the other hand, lives in
environment with better sanitation and adequate facilities to live with such as in the city of Kuala Lumpur.
Comparable data of worm infection between urban and rural settings are few but it is always assume that

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hookworm is more prevalent in rural areas whereas A. lumbricoides and T. trichiura are more prevalent
in urban area 65. However, based on the prevalence data of STH in Malaysia, there is no significant
difference between rural and urban children whereby both A. lumbricoides and T. trichiura are high in
prevalence rate even though there are contrast environmental conditions between the two different
settings (Table 2).

For example, a study by Kan (1984) showed high prevalences of T. trichiura among primary
school-children in urban and rural areas of Kuala Lumpur at 90.7% and 92.7% respectively but infection
by hookworm is higher (42.4%) than A. lumbricoides in rural setting 54. Rajeswari et al. (1994) also
reported T. trichiura with the highest prevalence rate at 47.1% among children of Gombak 52 . A study
by Lo et al. (1979) showed that A. lumbricoides is the dominant species of STH affecting the lives of
rural school-children at a rate of 86.7%, followed by T. trichiura at 84.5% 44. Sinniah et al. (2014) also
found that T. trichiura is the most common helminth among children from different areas at 20.2%
followed by A. lumbricoides (10.5%) and even though hookworm has a low prevalence rate of 6.7%,
there is no case reported in urban children 55. More than 40 years ago, hookworm was found to be as
20 44
high as 95% but as socio-economic development has improved, the infection rate tend to decrease
even among the indigenous communities. Plus, unlike T. trichiura and A. lumbricoides, hookworm
infection predominantly affects adults which may contribute to the decreasing rate of infection among
children. According to Hanjeet et al. (1991), the general unsuitable soil which is needed for development
and maturation purposes may contribute to the low prevalence of of hookworm in many parts of Malaysia
66
.

Hence, the most prevalent STH in this region is T. trichiura, even though mix-infection is common,
particularly with A. lumbricoides 24. This species of STH is partly responsible for the high prevalence of
infection in various communities ranging from the remote indigenous aborigine as well as urban dwellers.
This may be due to relatively long life span and higher resistance to many anthelminthic drugs 23. Urban
population near squatter areas had high infection of the so-called whipworm as well due to poverty,
cultural factors, environmental sanitations with the highest prevalence rate among the primary six school
children 67. This is evident in several reports among children of urban slums, particularly in the federal
42, 64, 66, 67
territory of Kuala Lumpur . Until present, this particular species still continues to show its
dominancy as the most prevalent worm infection in Malaysia 68, 69. However, published information and
comparable data of STH and other worm infections between urban and rural settings in East Malaysia is
still very scarce or possibly none since most of the studies conducted and published were from rural
communities.

Several studies in 1990s showed a high prevalence of either one or more STH infections in among
the children of aboriginal communities in Malaysia 47, 50, 70-73. The rate of infection was reportedly reduced

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over the years but studies still reveal high prevalence of STH infection among the indigenous minority
74
people . Hartini et al. (2013) indicated that overall prevalence for STH infection among aborigine
children in Pos Sungai Rual, Kelantan was considerably high at 87.4% 28. Studies by Al-Mekhlafi et al
(2005-2007) showed among the highest prevalence of STH at 98.2% - 100% among Orang Asli children
since 1970. This showed that despite comprehensive development towards health care and
socioeconomic improvements in Malaysia, STH infection, particularly T. trichiura, remain a burden to
the country that needs further effective intervention program and strategies for many generations to come.

Worm infection is the most common parasitic disease in the world and prevalence varies greatly
depending on the endemicity and different regions of developing countries across the globe as well as the
age which predominantly affecting the youngest generation of human being. Worm infection among
children is a public health concern due to the negative consequences to a child’s health and development
both mentally and physically as infection is associated with a range of significant growth impairment. In
contrast to other developing countries however, the condition and quality of life of children in Malaysia
have improved as this country is progressing and moving forward towards a developed nation. Malaysian
government continue its effort to reduce poverty and improve the well-being of the people by providing
education compulsory for children, safe and treated drinking water, latrine facility, as well as primary
healthcare services that provide periodic deworming treatment in local clinics and hospitals.
Nevertheless, despite all these effort, there are still many populations especially the Orang Asli, rural and
remote communities plagued with STH infection and other helminthiasis due to their lifestyle,
involvement with agricultural sectors and industrialization which has resulted in undergoing rapid
urbanization and change in land-use.

Morbidity and mortality is considered very low in Malaysia, hence parasitic worm infection is
usually neglected and considered not important. Statistical of parasitological data and information in
hospitals are limited too. Therefore, Malaysian government should encourage and provide more funds to
assist Malaysian researchers in related field to conduct more studies to further assess STH prevalence in
school-age population as well as investigating the risk factors of infection as there are still other remote
and rural communities who are considered hard-core poor such as in Sabah and Sarawak. Follow-up
studies should also be conducted to help distinguish clearly whether there is any decrease or increase in
the prevalence rate among the school-aged children who were examined since 1970.

Table 2: Studies of worm infection among children in Malaysia (1970-2014)

65
 Area Sample A. T. Hookworms Other Overall worm Reference
size lumbricoides trichiura helminths infection in children
(%) (%) (%)
Borneo Journal of Medical Sciences
(%) (2016) volume 10, issue
(%)1, pp: 59-74

Aboriginal 110 48 81 95 NA 87.3 Bisseru and Aziz, 1970 20

Aboriginal 231 S.japonicum-type ova in 9 autopsy Leong et al., 1975 38

cases
NA
(aged 11-68) with 3.9% overall
prevalence

Rural 834 86.7 84.5 43.2 95 Lo et al., 1979 44

Urban 7,682 21.9 44.5 4.6 50 George and OwYang,

1982 67
NA
Urban 305 17.4 14.8 2.9 39 Hamimah et al., 1982 45

Rural 271 41.2 74.2 28.0 86.3 Sinniah, 1984 53

Urban 389 37.5 53.7 5.4 1 case of 64 Sinniah, 1984 48

Strongyloides;
2 cases of H.
nana; cases of
E.vermicularis

Rural 342 36.9 92.7 42.4 38.9

NA Kan, 1984 54
Urban 688 75.6 90.7 2.9 75.6

Aboriginal 618 NA Schistosomes ova found in stool of

children aged 2 months-18 years old Lai et al., 1986 41

Rural and 11,874 19.3 36.2 3.3 41.1

urban slum Kan and Poon, 1987 42

NA
Island 1,286 4.0 4.7 0.2 8.4 (very low) Kan et al., 1987 57

Urban slum 1,574 49.6 62.8 5.3 66.7 Bundy et al., 1988 64

Island 1,352 E. vermicularis 56.9

NA – 56.9% Oothuman et al., 1989 17

Estate 1,203 71.6 82.8 14 83.2 Li, 1990 76

NA
Urban 9,863 33 49 6 58 Hanjeet et al., 1991 66
slums

Rural 363 29.2 16.5 NA NA 38.8 Hidayah et al., 1997 77

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Aboriginal 205 63 92 29 92 Norhayati et al., 1997 71

Aboriginal 84 59.5 41.7 6.0 S. stercoralis 79.8 Rahmah et al., 1997 47

(1.2%)

Aboriginal 259 47.5 33.9 6.2 56.0 Zulkifli et al., 1999 50

Rural 183 62.8 38.9 12.6 69.4 Zulkifli et al., 2000 51

Aboriginal 368 61.9 98.2 37.0 98.2 Al-Mekhlafi et al., 2005 27

Aboriginal 292 67.8 95.5 13.4 100 Al-Mekhlafi et al., 2007 25

Rural 550 41.6 71.5 13.5 76.5 Ngui et al., 2012 78

Aboriginal 254 47.6 84.6 3.9 NA 93.7 Ahmed et al., 2012 73

Aboriginal 111 40.5 65.8 25.2 87.4 Hartini et al., 2013 28

Aboriginal 189 12.7 28.0 12.2 32.3

and Rural

Urban Slum 97 12.4 13.4 NA 20.6 Sinniah et al., 2014 55

Urban 56 3.6 3.6 NA 5.4

(Flats)

EAST MALAYSIA

Rural 120 STH infections recorded exactly 1/3rd 40 Kan et al., 1987 58

Rural 264 12.8 25.4 7.2 33.6 Lee et al., 1999 59

Rural NA NA Schistosomiasi 6.8 Sagin et al., 2001 60

s (seroprevalence)

Rural 355 7.0 37 5 NA 41 Sagin et al., 2002 46

Rural 150 8.7 10 3.3 NA NorAza et al., 2003 61

Rural 135 NA Cysticercosis 2.2 Noor Azian et al., 2006 62

(seroprevalence)

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Furthermore, education is also very important not only school-based but also community-based
with the participation of the community themselves as well as government and other agencies. Literacy
in parents and children, public awareness about personal hygiene, proper nutrition and environmental
sanitation are crucial in improving the living status and well-being of the population, especially children
at risk. It is definitely the right time now to embark on intensified community-based programmes and
empowerment to effectively eradicate worms in the country. It is also not possible for the local
community of a particular population who have succeeded in bring down the infection rate to help to
implement the same programme to other improved population in the neighbouring countries such as in
South-east Asia region.

Besides conducting studies, improvements in sanitation and education, regular treatment of anti-
helminthic drugs for school-aged children prone to worm infection should be sustained and the progress
be monitored to effectively control worms and eventually be eliminated. Treatment for worm infection
75
is appropriate at a tender age of 7-12 years old child and regular treatment is fundamental since re-
infection may occur even after treatment. Failure in a treatment programme will hamper not only the
children development but also compromises the economic development of the nation. Hence periodic
deworming and chemotherapy through school should continue to be incorporated into existing worm
control programs, especially among primary school children.

CONCLUSION

Comparing the studies reported 20 years ago and 20 years later of the epidemiology of worm infection in
Malaysia, particularly STH infection, still persist among the children of diverse background ranging from
the Orang Asli, rural, urban slums and urban population. Hence, associated risk factors to the promotion
in the spread and transmission of worm infection need to be focused with great attention and identified
sustainably. More studies, including follow-up studies, should be conducted to assess and monitor the
prevalence rates of worm infection not only in Peninsular Malaysia but also East Malaysia. Furthermore,
Malaysian government should put more emphasis on the worm infection studies in Sabah and Sarawak,
not only limited to data collection of the prevalence rate but also the implementation of strategies to
control and eradicate the burden of STH and other helminths including Schistosomiasis among the
children at risk in Malaysia.

CONFLICT OF INTEREST: None

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